F0689

G

Failure to Prevent Oxygen-Related Smoking Injury

Bennington, Vermont Survey Completed on 03-11-2026

Penalty

Fine: $12,735

Summary

The facility failed to ensure a resident remained as free from accidents as possible related to the use of supplemental oxygen while smoking and did not provide adequate supervision. The resident, recently admitted to the LTC unit from residential care with diagnoses including nicotine dependence and respiratory failure, had a smoking assessment completed that identified them as an unsupervised smoker who could keep cigarettes but had to request a lighter. Nursing progress notes documented that on the night prior to the incident the resident experienced increasing agitation and confusion and was receiving 4 liters of continuous oxygen via nasal cannula.

At approximately 6:20 a.m., nursing staff observed black soot on the resident’s nose and burned oxygen tubing under their nose. When questioned, the resident stated that another resident had lit their cigarette and it had caught on fire. The resident sustained a painful facial burn measuring 0.67 cm in width, 1.53 cm in length, and 0.58 cm in area, with redness and loss of skin. Review of the care plan showed that the facility had not care planned the resident’s smoking status or the hazard associated with their oxygen use until the day after the burn occurred. The facility’s smoking policy, revised previously, stated that oxygen use is prohibited in smoking areas, and the DON confirmed that the resident went to the smoking room with oxygen on and was burned when the cigarette was lit, and that a sign prohibiting oxygen in the smoking room was not posted on the door until after the injury. This deficiency was cited as a repeat violation from the prior re-certification survey.